This blog post is part two of a series about how we supported the Ebola crisis with mobile applications for contact tracing. Check out this blog post to read more about the contact tracing application that was developed from our experience and collaborations in West Africa.
Over the past year I’ve had the opportunity to visit Liberia, Sierra Leone, and Guinea to learn about the role of mobile technology in Ebola response and recovery as part of the Fighting Ebola: a Grand Challenge for Development award from U.S. Agency for International Development (USAID). It has been an incredible experience to listen to stories of why healthcare systems failed to detect and manage the outbreak early on, the complex social and cultural issues that arose during the outbreak, and the infectious optimism of what can help solve future epidemics. In this blog post, I’ll cover how CommCare was used and the key lessons we learned from our work in West Africa.
How was CommCare used?
The main use case for CommCare in the response effort was for contact tracing. Contact tracing (demonstrated in this video by the Earth Institute) helps stop an outbreak by identifying and isolating potential cases efficiently so they can stop the spread of the disease and get early treatment. Contact Tracing is not only used in hemorrhagic fevers such as Ebola Virus Disease (EVD), it is also used for tracking Cholera, Polio, TB, HIV, and many other disease that are spread from human contact.
During the West Africa Ebola Outbreak, Dimagi had two major deployments for contact tracing — the first was a partnership with The Earth Institute, Tableau, and Ericsson which deployed a system for managing contact tracing in Guinea. A second collaboration with Innovations for Poverty Action, The London School of Hygiene and Tropical Medicine and GOAL deployed a separate contact tracing application in Sierra Leone. These organizations leveraged their shared knowledge to deploy applications that had an incredible impact on the efficiency of contact tracing in the communities that they served.
CommCare was not the only mobile health tool used in contact tracing, nor was it solely used for contact tracing in response efforts, however, CommCare is uniquely suited for this particular use case because of its flexibility and ability to handle complex case management workflows. Throughout our work with contact tracing, we have learned some key lessons that may help improve future app design for contact tracing applications — not just in Ebola and Hemorrhagic Fevers, but also for Cholera, Measles, Polio, and HIV, as well as how to leverage frontline workers in outbreak situations. We used this feedback to develop a starter application available on the CommCare Exchange, with the hope that future outbreaks can use these applications in deploying frontline workforces faster.
3 Lessons Learned from Contact Tracing During the Ebola Crisis:
1. Incorporate Visual Cues
Contact tracers often have to survey many people quickly and have a lot of work to do during their daily operations — it’s no small task to track daily visits. Visual cues such as a green checkbox and red X for yes and no questions, and having clear icons/images for questions and particular symptoms improve the end user experience, as well as ensure that the end user doesn’t need to be fully literate to use the application.
2. Don’t Overlook the Household Unit
Often in data collection we are focused on the individual as the base unit for data collection. While the individual is still considered the lowest denominator, the household unit is often overlooked in designing applications for case management. When contact tracers conduct visits, they go to the household, and then begin to ask their questions. It also seems to be more likely that if one person in the household is a contact, other people are as well. For example, if one family member is attending a funeral, it is highly likely that the whole family will join. In the case of a home of an Ebola case, we would track the whole household. In managing cases by the household, we can later look at household clusters (particularly important with diseases such as cholera), and shared risk factors among those households.
One great new feature in CommCare that we were able to include in building out the “Contact Tracing 2.0” application is using subcases to attach individuals to households, and households to Ebola patients. This means that when exporting data and working with reports, we can easily build hierarchies in relationships and access information about both the household and the contacts within the household that are being traced.
Another helpful new CommCare feature is to look at the cases in the case list using GPS! You can now look at a map on the phone to see which cases are nearby, and navigate to them using Google Maps.
3. Maintain Flexible Healthcare Workforces
Community Health Workers are well documented as an effective workforce. In an emergency situation, they can be utilized to conduct prevention and control methods if necessary. For example, during the Ebola outbreak, we saw organizations in Nigeria building in Contact Tracing modules based off of the application in Guinea in case they needed to transition community health workers working on maternal and child health into Ebola contact tracers. Furthermore, community health workers in Sierra Leone were both screening and spreading awareness on Ebola while conducting general health screening and tracking of HIV patients. With only a brief training, these frontline workers, who were already embedded within the community and trusted as healthcare providers, could provide critical information during outbreaks and serve as integral pieces to solving the epidemic. Equipping them with a tool such as CommCare, where a quick contact tracing or awareness module can easily be added to their applications, improves their ability to help out in these situations and provide accurate information.
Across all three countries, I heard many stories of areas that previously had no community health workers bringing in outsiders to conduct contact tracing. These contact tracers were met with hostility or sent away because they were “nosy busy bodies.” If we had been able to adapt previous CommCare projects for routine health care into contact tracing armies, it would have saved months of time in recruiting, training, and deploying new workforces.
This is where health systems strengthening meets emergency preparedness — building flexible workforces that are able to adapt to situations when necessary, because they are using tools that are also easily adaptable.